Cognitive behavioral therapy for substance use disorders

Cessation of self-reported opioid use and impacts on co-occurring health conditions

BACKGROUND

Among veterans in care reporting opioid use, we investigated the association between ceasing opioid use on subsequent reduction in report of other substance use and improvements in pain, anxiety, and depression.

METHODS

Using Veterans Aging Cohort Study survey data collected between 2003 and 2012, we emulated a hypothetical randomized trial (target trial) of ceasing self-reported use of prescription opioids and/or heroin, and outcomes including unhealthy alcohol use, smoking, cannabis use, cocaine use, pain, and anxiety and depressive symptoms. Among those with baseline opioid use, we compared participants who stopped reporting opioid use at the first follow-up (approximately 1 year after baseline) with those who did not. We fit logistic regression models to estimate associations with change in each outcome at the second follow-up (approximately 2 years after baseline) among participants with that condition at baseline. We examined two sets of adjusted models that varied temporality assumptions.

RESULTS

Among 2473 participants reporting opioid use, 872 did not report use, 606 reported use, and 995 were missing data on use at the first follow-up. Ceasing opioid use was associated with no longer reporting cannabis (adjusted odds ratio [AOR]=1.82, 95% confidence interval [CI] 1.10, 3.03) and cocaine use (AOR=1.93, 95% CI 1.16, 3.20), and improvements in pain (AOR=1.53, 95% CI 1.05, 2.24) and anxiety (AOR=1.56, 95% CI 1.01, 2.41) symptoms.

CONCLUSION

Cessation of opioid misuse may be associated with subsequent cessation of other substances and reduction in pain and anxiety symptoms, which supports efforts to screen and provide evidence-based intervention where appropriate.

A Transdiagnostic group therapy for sleep and anxiety among adults with substance use disorders: Protocol and pilot investigation

Introduction

Treatment of substance use disorders (SUDs) is challenging with high rates of treatment dropout and relapse, particularly among individuals with comorbid psychiatric conditions. Anxiety and insomnia are prevalent among those with SUD and exacerbate poor treatment outcomes. Interventions that concurrently target anxiety and insomnia during the early stages of SUD treatment are lacking. To this end, we investigated the feasibility and preliminary effectiveness in a single-arm pilot trial of an empirically informed group transdiagnostic intervention, Transdiagnostic SUD Therapy, to concurrently reduce anxiety and improve sleep among adults receiving treatment for SUD. Specifically, we hypothesized that participants would evidence declines in anxiety and insomnia and improvements in sleep health, a holistic, multidimensional pattern of sleep-wakefulness that promotes wellbeing. A secondary aim was to describe the protocol for Transdiagnostic SUD Therapy and how it may be implemented into a real-world addiction treatment setting.

Method

Participants were 163 adults (M_age  = 43.23; 95.1% White; 39.93% female) participating in an intensive outpatient program for SUD who attended at least three of four Transdiagnostic SUD Therapy sessions. Participants had diverse SUDs (58.3% alcohol use disorder, 19.0% opioid use disorder) and nearly a third of the sample met criteria for two SUDs and comorbid mental health diagnoses (28.9% anxiety disorder, 24.6% major depressive disorder).

Results

As anticipated, anxiety and insomnia reduced significantly across the 4-week intervention period from clinical to subclinical severity, and sleep health significantly improved (ps < 0.001). These statistically significant improvements following Transdiagnostic SUD Therapy demonstrated medium to large effects (ds > 0.5).

Conclusion

Transdiagnostic SUD Therapy is designed to be flexibly administered in "real-world" clinical settings and, preliminarily, appears to be effective in improving emotional and behavioral factors that increase risk for return to substance use and poor SUD treatment outcomes. Additional work is needed to replicate these findings, determine the feasibility of widespread uptake of Transdiagnostic SUD Therapy, and examine whether the treatment effects translate to improvement in substance use outcomes.

Emotion dysregulation mediates the relationship between adverse childhood experiences and problematic gaming

Gaming disorder (i.e., gaming addiction) is a relatively common mental health disorder with a worldwide prevalence rate of 3.05%. In the present research, we examined whether emotion dysregulation mediates the relation between adverse childhood experiences and problematic gaming in two samples of current video game players. The first sample consisted of 1,262 students recruited from five universities across Canada. The second sample comprised 417 community adults residing in Canada. Both samples of participants completed an online survey which included measures of adverse childhood experiences, problematic gaming, and emotion dysregulation. A total of 45.64% (n = 576) in the university sample and 49.76% (n = 205) in the community sample met the threshold for problematic gaming. In the student sample, adverse childhood experiences were positively associated with problematic gaming. In contrast, there was no significant association between adverse childhood experiences and problematic gaming in the community sample. In both samples, adverse childhood experiences were positively associated with emotion dysregulation, and emotion dysregulation was positively associated with problematic gaming. Importantly for the present research, emotion dysregulation mediated the relationship between adverse childhood experiences and problematic gaming in both the university and community sample. Although adverse childhood experiences are distal and static risk factors for problematic gaming, emotion dysregulation is a more proximal and modifiable risk factor. The results suggest that increasing adaptive emotion regulation skills may decrease the risk of problematic gaming among individuals who have experienced an adverse childhood experience.

Implications for a System of Care in Hawai'i: Primary Care Integration of Substance Use Disorder Treatment

Primary care physicians (PCPs) in Hawai'i face many challenges in treating patients with substance use disorders (SUD) who tend to have higher medical complexity and thus require more resources. PCPs play a vital role in identifying early misuse, integrating and coordinating care for patients with SUD including office-based interventions like medication-assisted treatment, and connecting patients to community treatment programs. In addition to enormous burdens to care for and increasingly complex patient panels, the challenges include lack of education on addiction medicine, insufficient resources and SUD treatment programs in the office and community, low reimbursement for the complexity of care provided, and an overall physician shortage which drives higher patient volume and less time for any given physician. This article suggests responses to address these challenges such as providing more training and continuing education in SUD for PCPs and trainees, enhancing team-based care to better support PCPs, and funding more SUD treatment programs. More funding should widen accessibility to treatment and reduce the overall burden on the health care system by preventing or treating the disease early, which is a core principle of primary care. Additionally, incentives to practice in Hawai'i in primary care, and especially to treat patients with SUD, need to be improved. Such steps must be taken to address the overall physician shortage that limits patients' access to SUD treatment. A collaborative care model between PCPs, care managers, and addiction specialists is an example of an integrated care system that may address many of these challenges in the short term. To truly improve care for all in Hawai'i, however, system wide interventions are essential to increase the incentive for PCPs to remain and practice in Hawai'i to take care of its unique population, including those dealing with SUD.

Experience of psychologists in the delivery of cognitive behaviour therapy in a non-western culture for treatment of substance abuse: a qualitative study

BACKGROUND

Psychotherapy is the preferred form of treatment for psychological disorders worldwide. Cognitive behaviour therapy (CBT) is one of the most widely used psychotherapies due to its proven efficacy for psychological disorders, including substance abuse. However, CBT was developed in the West according to the culture of developed countries. Therefore, it requires cross-cultural adaptation for non-Western countries. Pakistan is one of the developing non-Western countries where substance use disorders are increasing at an alarming rate. Despite the proven efficacy of CBT for substance use disorders, there is a dearth of its utilization in Pakistan. Therefore, in the present study, in-depth qualitative interviews were conducted with CBT practitioners in Pakistan to understand barriers and challenges in this regard. The study was a part of a broader project aimed at cultural adaptation of CBT for people with substance use disorders (SUDs) in Pakistan.

METHODS

In-depth qualitative interviews were conducted with CBT practitioners (N = 8) working in rehabilitation centres and hospitals in Islamabad, Pakistan. Thematic content analysis was conducted to develop core themes from the data.

RESULTS

CBT for SUDs requires some adjustments according to Pakistani culture for successful utilization. The challenges in providing CBT for SUDs revolved around three main themes, i.e., the mental health system, societal practices, and therapeutic issues, and 10 subthemes.

CONCLUSION

In order to utilize the benefits of CBT for SUDs in Pakistan, cultural adaptation is necessary as an initial step. However, its delivery requires stringent modifications in the health care system to address these challenges.

Smoking Mostly Alone as a Risk Factor for Cannabis Use Disorders and Depressive Symptoms

The empirically grounded etiological models of cannabis use already include a vast range of psychological factors (within an individual), paving the ground for individualized prevention and intervention programs. However, the interpersonal (among individuals) and relational variables influencing the emergence of excessive cannabis use are less understood. Particularly, the impact of consumption context (i.e., smoking alone or with others) on cannabis use intensity in youth remains to be clarified. We evaluated how smoking mostly alone modulates cannabis use disorders (CUD) and depressive symptoms in college students. A sample of 854 individuals from France (568 women, 286 men) who used cannabis in the last 6 months completed self-report questionnaires evaluating cannabis consumption, CUD symptoms, and depressive symptoms. Mostly alone users presented higher current use frequency as well as increased CUD and depressive symptoms compared to mostly social users. Smoking mostly alone remained positively correlated with CUD and depressive symptoms, even when controlling for current use frequency. The association between smoking mostly alone and depressive symptoms was significant before adjustment for symptoms of CUD. The loss of significance of this association after control reflected the mediating effects of symptoms of CUD on the relationship between smoking mostly alone and depressive symptoms. These results suggest that smoking mostly alone constitutes a risk factor for uncontrolled cannabis use and promote the relationship between cannabis use and depressive disorders, potentially through loneliness and social isolation. Longitudinal studies are required to identify the causal mechanisms underlying the links between smoking mostly alone, cannabis use and psychopathological disorders.

Identifying Biomarkers for Accurate Detection of Stress

Substance use disorder (SUD) is a dangerous epidemic that develops out of recurrent use of alcohol and/or drugs and has the capability to severely damage one's brain and behaviour. Stress is an established risk factor in SUD's development of addiction and in reinstating drug seeking. Despite this expanding epidemic and the potential for its grave consequences, there are limited options available for management and treatment, as well as pharmacotherapies and psychosocial treatments. To this end, there is a need for new and improved devices dedicated to the detection, management, and treatment of SUD. In this paper, the negative effects of SUD-related stress were discussed, and based on that, a few significant biomarkers were selected from a set of eight features collected by a chest-worn device, RespiBAN Professional, on fifteen individuals. We used three machine learning classifiers on these optimal biomarkers to detect stress. Based on the accuracies, the best biomarkers to detect stress and those considered as features for classification were determined to be electrodermal activity (EDA), body temperature, and a chest-worn accelerometer. Additionally, the differences between mental stress and physical stress, as well as different administrations of meditation during the study, were identified and analysed. Challenges, implications, and applications were also discussed. In the near future, we aim to replicate the proposed methods in individuals with SUD.

Alcohol Use Disorder: Neurobiology and Therapeutics

Alcohol use disorder (AUD) encompasses the dysregulation of multiple brain circuits involved in executive function leading to excessive consumption of alcohol, despite negative health and social consequences and feelings of withdrawal when access to alcohol is prevented. Ethanol exerts its toxicity through changes to multiple neurotransmitter systems, including serotonin, dopamine, gamma-aminobutyric acid, glutamate, acetylcholine, and opioid systems. These neurotransmitter imbalances result in dysregulation of brain circuits responsible for reward, motivation, decision making, affect, and the stress response. Despite serious health and psychosocial consequences, this disorder still remains one of the leading causes of death globally. Treatment options include both psychological and pharmacological interventions, which are aimed at reducing alcohol consumption and/or promoting abstinence while also addressing dysfunctional behaviours and impaired functioning. However, stigma and social barriers to accessing care continue to impact many individuals. AUD treatment should focus not only on restoring the physiological and neurological impairment directly caused by alcohol toxicity but also on addressing psychosocial factors associated with AUD that often prevent access to treatment. This review summarizes the impact of alcohol toxicity on brain neurocircuitry in the context of AUD and discusses pharmacological and non-pharmacological therapies currently available to treat this addiction disorder.

Discrimination experiences, resilience, and cardiovascular disease risk factors among sexual minority women

Resilience, or the process of adapting to adversity, may protect against the harmful effects of minority-related stressors on the cardiovascular health of sexual minority women (SMW). An online survey was conducted in a sample of cisgender, non-heterosexual women to evaluate resilience as a moderator of the association between discrimination experiences and key cardiovascular disease (CVD) risk factors: stress, tobacco-smoking, hazardous alcohol consumption, poor diet quality, physical inactivity, and sedentary behaviors. Overall, 191 women (mean age = 29.34, SD = 6.92; 84.5% White) completed the survey and met eligibility to be included in the data analysis. White race (b = - 6.71, SE = 2.49) and education (b = - 3.36, SE = 0.56) were each independently associated with fewer discrimination experiences. Latinx ethnicity was associated with more discrimination experiences (b = 9.34, SE = 2.61). Education was associated with greater resilience (b = 4.57, SE = 0.83). Multivariable regression models were adjusted for race, ethnicity, and education. Discrimination was associated with a higher likelihood of smoking in the past month (b = 0.04, SE = 0.02) and drinking at hazardous levels (b = 0.09, SE = 0.02). Resilience was associated with less stress (b =  - 0.15, SE = 0.02), a lower likelihood of hazardous alcohol consumption (b =  - 0.02, SE = 0.01) and less time spent engaging in sedentary behaviors (b =  - 0.02, SE = 0.01). One moderation emerged, such that discrimination was negatively associated with stress for those low in resilience (b =  - 1.75, SE = 0.58), and not associated with stress for those high in resilience. These findings may inform the development of CVD-risk reduction interventions for SMW, which could include both strategies to mitigate the effects of discrimination on substance use and coping skills to promote resilience.

Experiences of a therapist-guided internet-delivered intervention for hazardous and harmful drinking. A qualitative study

BACKGROUND

Alcohol is the third leading risk factor for burden of disease in the world, causing significant health damage to the individual as well as costs to the surroundings and society as whole. Internet-delivered psychological interventions may help the individual to address alcohol consumption at an early stage before it develops into more serious problems. There is a need to investigate how participants experience internet-delivered interventions for hazardous and harmful drinking to optimize its usefulness in the target population.

METHODS

The present study was part of an open pre-post pilot trial to evaluate the feasibility and acceptability of a therapist-guided internet-delivered cognitive behavioural intervention for hazardous and harmful alcohol use. The aim was to investigate participants` experiences of the intervention and the ways in which the intervention helped them to address their alcohol consumption. Fifteen participants were selected from the open pre-post trial (n = 32), and semi-structured interviews were conducted immediately after participants had completed the treatment. The interviews were analysed using Thematic Analysis.

RESULTS

The results indicate that most of the participants found the intervention to be useful. Participants reported that the intervention made them more aware of the consequences of excessive drinking and gave them tools to cope with their alcohol consumption. Among the perceived advantages were the flexibility and anonymity of the intervention and therapist support. Participants called for more individualisation of the treatment to meet individual needs.

CONCLUSIONS

A therapist-guided internet-delivered intervention for hazardous and harmful drinking can help individuals to address their alcohol consumption and give them tools to cope with their drinking. Future studies should examine the feasibility of tailoring modules to individual needs.

Effectiveness of Remote Intensive Counseling Versus Outpatient Counseling in Substance Use Disorders: A Retrospective Cohort Study

Background

Substance use disorders are a serious and persistent U.S. public health problem. Although a number of therapy modalities exist, few studies assessed the comparative effectiveness of specific therapies. This study empirically evaluated whether remote intensive counseling (RIC) is more effective than outpatient therapy (OT) in relapse prevention over the period of nine months in patients aged 18-45 years with a history of substance use.

Methods

The current study utilized a retrospective correlational cross-sectional cohort quantitative research design with multiple between-group comparisons and fixed effects. The sample (n=296) included adults of both sexes, of diverse racial/ethnic backgrounds, and of socioeconomic status (SES) between 18-45 years of age who had been using an illicit addictive substance(s) for at least six months prior and had never participated in any treatment program previously. Individuals with alcohol and/or nicotine co-dependence were excluded.

Result and conclusion

Remote intensive counseling (RIC) is more effective for patients aged 18-45 years with a history of substance use than outpatient therapy (OT). RIC works better for single or never married females younger than 30-year-old with higher education. The use of RIC for other age and racial/ethnic groups should be guided by whether patients belong to a younger age cohort and/or a specific race/ethnicity.

Can psychedelic-assisted psychotherapy play a role in enhancing motivation to change in addiction treatment settings?

Despite growing availability of several evidence-based approaches in the treatment of substance use disorders, existing pharmacotherapy and psychosocial interventions continue to have significant limitations, such as low treatment retention rates and high rates of relapse. There is a need to develop new strategies and models to address these limitations and target underlying psychosocial drivers of addiction, such as motivation to change – a crucial factor in achieving positive addiction treatment outcomes. Re-emerging clinical evidence and literature signal the promise of psychedelic-assisted psychotherapies as being novel, adjunctive treatments for a range of mental health and substance use disorders, encouraging further research. However, there remains a lack of formally validated metrics to evaluate recovery capital and motivation, limiting interpretation of the growing psychedelic literature. This commentary describes the current state of this line of investigation and potential impact of psychedelic-assisted psychotherapy on enhancing motivation to change in addiction treatment, and the need for validated metrics to evaluate recovery motivation and capital to assess the potential for psychedelic-assisted psychotherapies to elicit positive, lasting changes in substance use behaviors among those seeking treatment.

Substance Use Treatment Using Cultural Arts and 12 Steps: Curriculum Training and Community-led Implementation in Zambia

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Evaluating training in 12 Step group therapy curriculum utilizing Zambian art forms.

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Zambian-led implementation of curriculum brings addiction treatment into communities.

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Training professionals changes perspectives on value of treating substance users.

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This curriculum-based treatment decreases client substance use frequency.

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This curriculum-based treatment increases client participation and motivation.

Introduction

Substance use in Zambia is stigmatized and treatment access is limited. Over 30,000 people are homeless in Lusaka, where one-quarter of homeless youth report use. Zambia's Ministry of Health recently developed policies targeting alcohol, suggesting Chainama, the only mental health hospital, offer treatment. Together, they endorsed training in the curriculum studied in this paper. We hypothesized training Zambian professionals would improve their perceptions of substance users and treatment. We then explored if treatment using the curriculum, as delivered to clients by training participants, would encourage client motivation to change, participation in groups, and reduce substance use frequency.

Methods

Part 1: One-hundred professionals were trained in a curriculum-based, literacy-free intervention employing cognitive behavioral and rational emotive behavior therapy techniques to explore 12 Steps of addiction recovery through Zambian art forms. Pre/post questionnaires captured perspectives around substance users and treatment. Part 2: Trained organizations delivered the curriculum in their communities. Twenty-five organizations rated feasibility and benefit of the curriculum. Data for 200 clients recorded pre/post motivation to change, open-sharing/participation, and frequency of substance use.

Results

While training significantly modified professionals’ perspectives regarding the value of offering treatment, their views of substance users did not change. Clients endorsed increases in “motivation to change” and “participation/open-sharing.” Frequency of alcohol, marijuana, inhalant, and cigarette use significantly decreased.

Conclusion

Training in the curriculum helped address a public health need, playing a role in increased motivational variables and decreased substance use. Research addressing this study’s limitations is encouraged.

Video abstract

For a video summary of this paper, please visit https://youtu.be/uDZTVxtzF1Y.

Opioid-specific medication-assisted therapy and its impact on criminal justice and overdose outcomes

BACKGROUND

The overlap between justice system involvement and drug use is well-documented. Justice-involved people who misuse opioids are at high risk for relapse and criminal recidivism. Criminal justice policymakers consider opioid-specific medication-assisted therapies (MATs) one approach for improving outcomes for this population. More research is needed that explores the impacts of opioid-specific MATs for justice-involved people.

OBJECTIVES

This study sought to assess the effects of opioid-specific MAT for reducing the frequency and likelihood of criminal justice and overdose outcomes for current or formerly justice-involved individuals.

SEARCH METHODS

Records were searched between May 7, 2021 and June 23, 2021. We searched a total of sixteen proprietary and open access databases that included access to gray literature and conference proceedings. The bibliographies of included studies and relevant reviews were also searched.

SELECTION CRITERIA

Studies were eligible for inclusion in the review if they: (a) assessed the effects of opioid-specific MATs on individual-level criminal justice or overdose outcomes; included (b) a current or formerly justice-involved sample; and (c) a randomized or strong quasi-experimental design; and c) were published in English between January 1, 1960 and October 31, 2020.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures as expected by The Campbell Collaboration.

MAIN RESULTS

Twenty studies were included, representing 30,119 participants. The overall risk of bias for the experimental studies ranged from "some" to "high" and for quasi-experimental studies ranged from "moderate" to "serious." As such, findings must be interpreted against the backdrop of less-than-ideal methodological contexts. Of the 20 included studies, 16 included outcomes that were meta-analyzed using mean log odds ratios (which were reported as mean odds ratios). Mean effects were nonsignificant for reincarceration (odds ratio [OR] = 0.93 [0.68, 1.26], SE = .16), rearrest (OR = 1.47 [0.70, 3.07], SE = 0.38), and fatal overdose (OR = 0.82 [0.56, 1.21], SE = 0.20). For nonfatal overdose, the average effect was significant (OR = 0.41 [0.18, 0.91], SE = 0.41, p < 0.05), suggesting that those receiving MAT had nearly 60% reduced odds of a nonfatal overdose.

IMPLICATIONS FOR POLICY PRACTICE AND RESEARCH

The current review supports some utility for adopting MAT for the treatment of justice-involved people with opioid addiction, however, more studies that employ rigorous methodologies are needed. Researchers should work with agencies to improve adherence to medication regimens, study design, and collect more detailed information on participants, their criminal and substance use histories, onset, and severity. This would help clarify whether treatment and control groups are indeed comparable and provide better insight into the potential reasons for participant dropout, treatment failure, and the occurrence of recidivism or overdose. Outcomes should be assessed in multiple ways, if possible (e.g., self-report and official record), as reliance on official data alone may undercount participants' degree of criminal involvement.

Use of a low frustration tolerance exercise for trainee therapists in a SP/SR framework

Application of a self-practice self-reflection (SP/SR) framework to clinical training programmes for those learning cognitive behavioural therapy (CBT) have demonstrated positive outcomes. These programmes have typically resulted in reports of enhanced learning, improved clinical skills, heightened empathy, improved interpersonal skills, increased self-awareness, and self-development for those undertaking such training. However, the utility of specific activities within this framework for enhancing trainees’ learning still requires exploration. This study sought to explore the use of a low frustration tolerance (LFT) exercise to enhance trainee’s learning around issues relating to frustration and discomfort tolerance. It also further explored the possible application of SP/SR as a form of competency-based assessment. The study was based on 41 student trainees that engaged in a self-directed LFT exercise. Written reflections on these exercises were then thematically analysed. From a competency basis, the exercise provided an approach for observing the trainee’s competency with formulation skills, intervention planning, and self-reflective capacity. Participants reported both personal and professional development outcomes from the exercise. These included a ‘deepened’ understanding of cognitive behavioural principles related to their experiences, both in terms of principles relating to maintenance of dysfunction and to creating change. Increased self-awareness and learning outcomes relating to the development of interpersonal skills were also commonly reported by trainees.

Key learning aims

(1)

Integrating Cognitive Dysfunction Accommodation Strategies Into Behavioral Interventions for Persons on Medication for Opioid Use Disorder

Background

Cognitive dysfunction is disproportionately prevalent among persons with opioid use disorder (OUD). Specific domains of cognitive dysfunction (attention, executive functioning, memory, and information processing) may significantly impede treatment outcomes among patients on medication for OUD (MOUD). This limits patient's ability to learn, retain, and apply information conveyed in behavioral intervention sessions. Evidence-based accommodation strategies have been integrated into behavioral interventions for other patient populations with similar cognitive profiles as persons with OUD; however, the feasibility and efficacy of these strategies have not yet been tested among patients on MOUD in a drug treatment setting.

Methods

We conducted a series of focus groups with 25 key informants (10 drug treatment providers and 15 patients on MOUD) in a drug treatment program in New Haven, CT. Using an inductive approach, we examined how cognitive dysfunction impedes participant's ability to retain, recall, and utilize HIV prevention information in the context of drug treatment.

Results

Two main themes capture the overall responses of the key informants: (1) cognitive dysfunction issues and (2) accommodation strategy suggestions. Subthemes of accommodation strategies involved suggestions about particular evidence-based strategies that should be integrated into behavioral interventions for persons on MOUD. Specific accommodation strategies included: use of a written agenda, mindfulness meditation, multi-modal presentation of information, hands-on demonstrations, and a formal closure/summary of sessions.

Conclusions

Accommodation strategies to compensate for cognitive dysfunction were endorsed by both treatment providers and patients on MOUD. These accommodation strategies have the potential to enhance the efficacy of behavioral interventions to reduce HIV transmission among persons on MOUD as well as addiction severity, and overdose.

Clinical utility of a hybrid secondary and relapse prevention program in adults with mild intellectual disability or borderline intellectual functioning in community residential and day habilitation settings

BACKGROUND

Despite evidence that standard substance use disorder (SUD) treatment may be less effective in people with intellectual disability (ID), there is an absence of appropriate clinical tools with which to support them.

OBJECTIVES

This study examined the clinical utility of an alcohol and other drug refusal skills intervention designed to be cognitively accessible to adults with ID METHODS: Thirty individuals at high risk for or in recovery from a SUD in developmental disability services (DDS) community residential and day habilitation settings participated in the two-week refusal skills group. Measures included pretest versus posttest improvement in refusal skill competency and baseline performance on a standardized verbal learning test.

RESULTS

There was a strong effect for refusal skill acquisition (p < .001); and the magnitude of skill acquisition was predicted by group attendance (p < .001) and not by individual differences in verbal learning ability (p = .074) or efficiency (p = .35).

CONCLUSIONS

The Refusal Skills Group is developmentally appropriate for people with mild ID in that: (1) they can learn and demonstrate refusal skills and (2) their skill acquisition is predicted more strongly by exposure to the intervention than by individual differences in learning characteristics. Delivering refusal skills in DDS settings familiar to clients increased their access to services and minimized disruption to their usual routines and schedules.

Adaptive Text Messaging for Postpartum Risky Drinking: Conceptual Model and Protocol for an Ecological Momentary Assessment Study (Preprint)

Background

Risky drinking is prevalent among women of childbearing age. Although many women reduce their drinking during pregnancy, more than half return to prepregnancy levels during the early postpartum period. Risky drinking in new mothers may be associated with negative child and maternal health outcomes; however, new mothers are unlikely to seek treatment for risky drinking because of stigma and fear of child protective service involvement. SMS text messaging is a promising approach for reaching non–treatment-seeking new mothers at risk because of risky drinking. SMS text messaging interventions (TMIs) are empirically supported for alcohol use, but a tailored intervention for new mothers does not exist. This study aims to fill this gap by developing a just-in-time adaptive TMI for postpartum risky drinking.

Objective

The objectives of this paper are to present a preliminary conceptual model of postpartum risky drinking and describe the protocol for conducting an ecological momentary assessment (EMA) study with new mothers to inform the refinement of the conceptual model and development of the TMI.

Methods

This paper presents a preliminary conceptual model of postpartum risky drinking based on the motivational model of alcohol use, social cognitive theory, and temporal self-regulation theory. The model proposes three primary intervention targets: motivation, self-efficacy, and self-regulation. Theoretical and empirical literature in support of the conceptual model is described. The paper also describes procedures for a study that will collect EMA data from 30 participants recruited via social media and the perinatal Central Intake system of New Jersey. Following the baseline assessment, EMA surveys will be sent 5 times per day for 14 days. The assessment instruments and data analysis procedures are described.

Results

Recruitment is scheduled to begin in January 2022 and is anticipated to conclude in March 2022. Study results are estimated to be published in July 2022.

Conclusions

The study findings will enhance our understanding of daily and momentary fluctuations in risk and protective factors for risky drinking during the early postpartum period. The findings will be used to refine the conceptual model and inform the development of the TMI. The next steps for this work include the development of intervention components via an iterative participatory design process and testing of the resulting intervention in a pilot microrandomized trial.

International Registered Report Identifier (IRRID)

PRR1-10.2196/36849

Patient Engagement With a Game-Based Digital Therapeutic for the Treatment of Opioid Use Disorder: Protocol for a Randomized Controlled Open-Label, Decentralized Trial

BACKGROUND

Prescription digital therapeutics are software-based disease treatments that are regulated by the US Food and Drug Administration; the reSET-O prescription digital therapeutic was authorized in 2018 and delivers behavioral treatment for individuals receiving buprenorphine for opioid use disorder. Although reSET-O improves outcomes for individuals with opioid use disorder, most of the therapeutic content is delivered as narrative text. PEAR-008 is an investigational device based on reSET-O that uses an interactive, game-based platform to deliver similar therapeutic content designed to enhance patient engagement, which may further improve treatment outcomes.

OBJECTIVE

We aim to investigate how participants interact with the prescription digital therapeutic's new content delivery format. Secondary objectives include evaluating treatment success, symptoms of co-occurring mental health disorders, recovery capital, and skill development.

METHODS

Due to the COVID-19 pandemic, this study was redesigned using a decentralized model because it was not possible to conduct medication initiation and study visits in person, as initially intended. A decentralized, randomized controlled trial design will be utilized to compare patient engagement with PEAR-008 and that with reSET-O using both subjective and objective assessments. The study population will consist of approximately 130 individuals with opioid use disorder (based on Diagnostic and Statistical Manual of Mental Disorders 5 criteria) who have recently started buprenorphine treatment for opioid use disorder. Participants will be virtually recruited and randomly assigned to receive either PEAR-008 or reSET-O. All study sessions will be virtual, and the duration of the study is 12 weeks. The primary outcome measure of engagement is operationalized as the number of active sessions per week with either PEAR-008 or reSET-O. (An active session is any session that contains some active participation in the app, such as navigating to a different screen, engaging with a learning module, or responding to a notification.) Subjective dimensions of engagement will be assessed with participant surveys. The hypothesis is that PEAR-008 will have significantly greater participant engagement than reSET-O.

RESULTS

As of February 2021, participant enrollment is ongoing.

CONCLUSIONS

This randomized controlled trial will investigate if changing the delivery format and enhancing the content of a prescription digital therapeutic for opioid use disorder will affect how participants use and interact with the prescription digital therapeutic. The study design may serve as a useful model for conducting decentralized studies in this patient population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04542642; https://clinicaltrials.gov/ct2/show/NCT04542642.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/32759.

Inserção das Estratégias Cognitivo-Comportamentais no CAPS Álcool e Drogas

Resumo Este estudo teve como objetivo conhecer a percepção de psicólogos que trabalham em Centros de Atenção Psicossocial para Álcool e Drogas sobre a inserção de estratégias das terapias cognitivo-comportamentais para o tratamento de dependência de álcool e outras drogas em sua prática. Foi realizado um estudo qualitativo de caráter exploratório, por meio de entrevistas com 16 psicólogos que atuam no Rio de Janeiro e em Minas Gerais. Os dados coletados foram analisados por meio da análise de conteúdo temática de Bardin. Os resultados apontam que, na percepção dos psicólogos, essas estratégias são passíveis de serem adotadas por esses centros e conferem bons resultados ao tratamento, embora haja limitações na formação especializada em terapia cognitivo-comportamental para lidar com a dependência de drogas entre os participantes. São discutidas a contribuição dessas terapias para a prática baseada em evidências no serviço público no que se refere ao monitoramento e avaliação de resultados, bem como sua relação compatível com a estratégia de redução de danos e com a lógica do tratamento psicossocial. Apesar das terapias cognitivo-comportamentais serem reconhecidas em outros países como intervenções bem embasadas cientificamente e apresentarem características importantes para a saúde pública, persistem obstáculos para a adoção destas ferramentas no tratamento da dependência de álcool e outras drogas nos serviços de saúde mental no Brasil.

Getting High or Getting By? An Examination of Cannabis Motives, Cannabis Misuse, and Concurrent Psychopathology in a Sample of General Community Adults

OBJECTIVE:

Few studies have examined cannabis motives in adults and, although associations between cannabis use and psychiatric conditions are well documented, there has been limited investigation of the intersection of cannabis use, cannabis motives, and psychopathology. In a sample of community adults, the present study examined cannabis motives in relation to cannabis misuse, and investigated whether motives linked cannabis misuse with concurrent psychiatric symptoms.

METHOD:

Participants (N = 395; M_age = 34.8; %F = 47.6; % White = 81.3%) completed assessments related to cannabis misuse, cannabis use motives, and symptoms of depression, anxiety, PTSD, and somatic experiences. Bivariate correlations, hierarchical regressions, and indirect effect analyses were performed to examine associations between motives and cannabis misuse and to investigate mechanistic relationships between psychiatric symptoms and cannabis misuse.

RESULTS:

Regressions revealed significant associations between cannabis misuse and social (β = .13, P < .02), enhancement (β = .12, P < .02), and coping motives (β = .48, P < .001). Indirect effects were present such that coping motives consistently linked psychiatric and somatic symptoms with cannabis misuse (anxiety: unstandardized effect = 0.26,and 95% CI = 0.17-0.37; depression: unstandardized effect = 0.12, CI = 0.11-0.25; PTSD: unstandardized effect = 0.07, CI = 0.04-0.10; somatic symptoms: unstandardized effect = 0.20, CI = 0.11-0.30). In addition, enhancement motives exhibited an indirect effect (unstandardized effect = 0.02, CI = 0.002-0.04) between depressive symptoms and cannabis misuse.

CONCLUSION:

These results support a negative reinforcement motivational profile as the predominant pattern in adult cannabis users, albeit with links to enhancement and social motives. This motivational profile is especially pronounced with regard to comorbid psychopathology and cannabis misuse. These results support the importance of treatment strategies targeting maladaptive coping to address cannabis misuse and co-occurring psychopathology.

Using Anger Management Virtual Reality Cognitive Behavior Therapy to Treat Violent Offenders with Alcohol Dependence in South Korea: A Preliminary Investigation

Cognitive Behavior Therapy (CBT) effectively treats impulse/anger attacks and aggressive-impulsive behaviors, frequently conducted concerning domestic violence, among patients with alcohol dependence. CBT combined with virtual reality (VR) is a new and beneficial psychotherapeutic intervention for patients and violent offenders with impulse-anger control problems and alcohol dependence. This clinical study evaluated the effects of the “anger management virtual reality cognitive behavior therapy (AM-VR-CBT)” and motivational interviewing (MI) intervention program on quantitative electroencephalography (QEEG) mapping patterns among violent offenders with alcohol dependence (N = 29) in the National Probation Service. A clinical sample of twenty-nine violent offenders with alcohol dependence, who were evaluated and diagnosed with destructive and impulse-control disorders (DICD), underwent AM-VR-CBT combined with MI. The sessions lasted 150 minutes (AM-VR-CBT: 90 min; MI: 60 min) and were conducted twice a week for three weeks (six sessions). The intervention outcomes were measured using advanced QEEG brain mapping and standardized neurocognitive, emotional, and behavioral inventories, including the Alcohol Dependence Scale (ADS), the Obsessive Compulsive Drinking Scale (OCDS), the Readiness to Change Questionnaire (RTCQ), the Barratt Impulsiveness Scale-II (BIS-II), the Beck Anxiety Inventory (BAI), the Beck Depression Inventory-Second Edition (BDI-2), and the State-Trait Anger Expression Inventory-2 (STAXI-2), to identify neuro-psycho-physiological changes in violent offenders with alcohol dependence. The Wilcoxon signed-rank test was used at p < 0.05. The intervention showed significant improvements and healthy behavioral changes related to obsessive drinking thoughts, compulsive drinking behaviors, attentional control, intrinsic motivation, worry, anxiety, depression, impulse-anger control issues, aggressive behaviors, over-control, interpersonal relationships, self-efficacy, self-reflection, self-inhibition, creativity, mental navigation/imagery, and episodic memory retrieval among violent offenders with alcohol dependence. Therefore, the results demonstrate the efficacy of the novel and promising clinical evidence-based implementation of the AM-VR-CBT + MI program intervention for non-invasive neuromodulation and related neuro-psycho-physiological, neurocognitive, emotional, and behavioral changes among violent offenders demonstrating alcohol dependence, impulse-anger control, and aggressive behaviors.

Historical Trends in Veteran Community Substance Use Treatment: 2000-2019

Background: Substance use is a significant health crisis for the Veteran population. Prior research has thoroughly examined Veteran substance use within Veterans Health Administration (VHA) settings. However, such data tends to be outdated, and there is minimal research on substance use services delivered outside of VHA systems. This study examines historical patterns of Veteran substance use using a large sample of community-based substance-use treatment admissions. Methods: Data were drawn from the Substance Abuse and Mental Health Data Archive Treatment Episode Data Set-Admissions. Of the 39,425,886 total admissions between 2000 and 2019, 1,361,339 were of Veterans. Analyses compared Veteran versus non-Veteran admissions on demographics and historical trends in nature of substance-use admissions. Results: Relative to non-Veterans, Veteran admissions were more likely to be prompted by alcohol use. Over time, heterogeneity in substances prompting admissions has increased dramatically for both Veterans and non-Veterans, with particularly notable increases in opiate and stimulant use. Conclusion: Results suggest Veterans admitted to community substance-use treatment are unique relative to their non-Veteran peers. Development and implementation of treatments to target a range of substances while also considering the environmental challenges (e.g., homelessness) commonly faced by this population appear essential to best servicing community-based Veterans.

Visualizing a Calculus of Recovery: Calibrating Relations in an Opioid Epicenter

This article uses participatory photography to explore the relationships animating efforts towards recovery from opioid use disorder (OUD) in the Dayton, Ohio area, an epicenter of illicit opioid use and overdose death. A photo-elicitation project was conducted with thirteen people who met the DSM-5 criteria for OUD. Photographs were used as prompts during qualitative interviews, which were thematically analyzed. Analysis of both visual and textual data demonstrated the ways in which recovery became an unfolding process of calculation as participants made strategic choices to navigate relations and encounters with things, people, and places. Relationships across each of these domains could, under some circumstances, serve as supports or motivators in the recovery process, but, in alternate settings, be experienced as "triggers" prompting a resumption of problematic drug use or, at the very least, a reckoning with the feelings and emotions associated with painful or problematic aspects of personal histories and drug use experiences. Findings highlight the importance of understanding recovery as a calibration of the ambiguous relations animating experiences of everyday life. We argue for continued emphasis on recovery as an active performance and ongoing practice of calculation-of risks and benefits, of supports and triggers, of gratification and heartbreak-rather than a goal or static state.

Barriers and facilitators of HIV and hepatitis C care among people who inject drugs in Nairobi, Kenya: a qualitative study with peer educators

BACKGROUND

In Kenya, people who inject drugs (PWID) are disproportionately affected by HIV and hepatitis C (HCV) epidemics, including HIV-HCV coinfections; however, few have assessed factors affecting their access to and engagement in care through the lens of community-embedded, peer educators. This qualitative study leverages the personal and professional experiences of peer educators to help identify HIV and HCV barriers and facilitators to care among PWID in Nairobi, including resource recommendations to improve service uptake.

METHODS

We recruited peer educators from two harm reduction facilities in Nairobi, Kenya, using random and purposive sampling techniques. Semi-structured interviews explored circumstances surrounding HIV and HCV service access, prevention education and resource recommendations. A thematic analysis was conducted using the Modified Social Ecological Model (MSEM) as an underlying framework, with illustrative quotes highlighting emergent themes.

RESULTS

Twenty peer educators participated, including six women, with 2-months to 6-years of harm reduction service. Barriers to HIV and HCV care were organized by (a) individual-level themes including the competing needs of addiction and misinterpreted symptoms; (b) social network-level themes including social isolation and drug dealer interactions; (c) community-level themes including transportation, mental and rural healthcare services, and limited HCV resources; and (d) policy-level themes including nonintegrated health services, clinical administration, and law enforcement. Stigma, an overarching barrier, was highlighted throughout the MSEM. Facilitators to HIV and HCV care were comprised of (a) individual-level themes including concurrent care, personal reflections, and religious beliefs; (b) social network-level themes including community recommendations, navigation services, family commitment, and employer support; (c) community-level themes including quality services, peer support, and outreach; and (d) policy-level themes including integrated health services and medicalized approaches within law enforcement. Participant resource recommendations include (i) additional medical, social and ancillary support services, (ii) national strategies to address stigma and violence and (iii) HCV prevention education.

CONCLUSIONS

Peer educators provided intimate knowledge of PWID barriers and facilitators to HIV and HCV care, described at each level of the MSEM, and should be given careful consideration when developing future initiatives. Recommendations emphasized policy and community-level interventions including educational campaigns and program suggestions to supplement existing HIV and HCV services.

An Inquiry into the Relationship between Drug Users' Psychological Situations and Their Drug-Taking Behaviour

In view of the research gap whereby few studies have investigated the inner psychological situations underlying continuous drug use, this study used the Soulmate Scale to investigate the relationship between soulmate experience and drug-taking behaviour. Overall, 276 participants took part in this study. Results showed that soulmate experience was negatively related to drug-taking behaviour, which means that being psychologically attached to drugs and receiving comfort from them encourages dependency and a higher level of difficulty in quitting drugs. In addition, soulmate experience significantly mediated the effect of meaning of life and social isolation on drugs, suggesting that when such psychological bonding and sustenance can be developed in interpersonal relationships instead of drugs, drug users are likely to develop the meaning of life and a lower sense of social isolation, and are more likely to quit drugs. The corresponding implications were discussed.

Targeting white matter neuroprotection as a relapse prevention strategy for treatment of cocaine use disorder: Design of a mechanism-focused randomized clinical trial

Cocaine use continues to be a significant public health problem with limited treatment options and no approved pharmacotherapies. Cognitive-behavioral therapy (CBT) remains the mainstay treatment for preventing relapse, however, people with chronic cocaine use display cognitive impairments that are associated with poor response to CBT. Emerging evidence in animal and human studies suggests that the peroxisome proliferator-activated receptor-gamma (PPAR- γ) agonist, pioglitazone, improves white matter integrity that is essential for cognitive function. This project will determine whether adjunctive use of pioglitazone enhances the effect of CBT in preventing relapse during the early phase of recovery from cocaine use disorder. This paper describes the design of a mechanism-focused phase 2 randomized clinical trial that aims first to evaluate the effects of pioglitazone on targeted mechanisms related to white matter integrity, cognitive function, and cocaine craving; and second, to evaluate the extent to which improvements on target mechanisms predict CBT response. Positive results will support pioglitazone as a potential cognitive enhancing agent to advance to later stage medication development research.

Integrated Trauma-Focused Psychotherapy for Traumatic Stress and Substance Use: Two Adolescent Case Studies

Post-traumatic stress disorder (PTSD) and substance use disorder (SUD) occur frequently as comorbid diagnoses among adolescents. Historically, these conditions have been treated using a sequential model; however, emerging evidence suggests that an integrated treatment model may be most effective. This article presents two de-identified clinical case studies from an ongoing randomised controlled trial examining the efficacy of an integrated, exposure-based, cognitive-behavioral psychotherapy (CBT) for PTSD and SUD among adolescents (COPE-A), relative to a supportive counselling control condition (person-centred therapy). In both case studies, participants were randomised to receive the COPE-A integrated treatment, which incorporates prolonged exposure (PE) including imaginal and in vivo exposure as a core treatment component alongside CBT for PTSD and SUD. The clinical profile and treatment response of each participant is discussed. Promising results were found in both cases, with substantially reduced traumatic stress symptoms and decreased or stable levels of substance use by the end of treatment. Clinical implications of these early findings are discussed.

A Review of Behavioral Therapies in Adolescents with Opioid Use Disorder

A growing evidence base supports the use of medication to treat opioid use disorder (OUD) in adolescents, but little is known about behavioral therapies for adolescents with OUD. A systematic review using PRISMA methodology was conducted on behavioral therapy for adolescent OUD. Only three studies were identified. Combined evidence from two studies indicates initial efficacy of the Adolescent-Community Reinforcement Approach, motivational enhancement therapy, and cognitive-behavioral therapy for reducing opioid use. The only group therapy identified, which involved adolescents and their parents, demonstrated improvement in participants' knowledge of relapse-prevention strategies, drug-refusal skills, and overall psychosocial functioning. Additional studies that included behavioral therapy but that did not specifically test its efficacy are also highlighted to expand the understanding of the small literature base. This review highlights the sparse evidence base for these therapies in this population. In addition, we highlight promising areas for future research and include evidence from the adult literature that may inform that research. Studies on behavioral therapies that utilize randomized, controlled trials for this population are imperative.

Predictive modeling of long-term opioid and benzodiazepine use after intradural tumor resection

BACKGROUND CONTEXT

Despite increased awareness of the ongoing opioid epidemic, opioid and benzodiazepine use remain high after spine surgery. In particular, long-term co-prescription of opioids and benzodiazepines have been linked to high risk of overdose-associated death. Tumor patients represent a unique subset of spine surgery patients and few studies have attempted to develop predictive models to anticipate long-term opioid and benzodiazepine use after spinal tumor resection.

METHODS

The IBM Watson Health MarketScan Database and Medicare Supplement were assessed to identify admissions for intradural tumor resection between 2007 and 2015. Adult patients were required to have at least 6 months of continuous preadmission baseline data and 12 months of continuous postdischarge follow-up. Primary outcomes were long-term opioid and benzodiazepine use, defined as at least 6 prescriptions within 12 months. Secondary outcomes were durations of opioid and benzodiazepine prescribing. Logistic regression models, with and without regularization, were trained on an 80% training sample and validated on the withheld 20%.

RESULTS

A total of 1,942 patients were identified. The majority of tumors were extramedullary (74.8%) and benign (62.5%). A minority of patients received arthrodesis (9.2%) and most patients were discharged to home (79.1%). Factors associated with postdischarge opioid use duration include tumor malignancy (vs benign, B=19.8 prescribed-days/year, 95% confidence interval [CI] 1.1-38.5) and intramedullary compartment (vs extramedullary, B=18.1 prescribed-days/year, 95% CI 3.3-32.9). Pre- and perioperative use of prescribed nonsteroidal anti-inflammatory drugs and gabapentin/pregabalin were associated with shorter and longer duration opioid use, respectively. History of opioid and history of benzodiazepine use were both associated with increased postdischarge opioid and benzodiazepine use. Intramedullary location was associated with longer duration postdischarge benzodiazepine use (B=10.3 prescribed-days/year, 95% CI 1.5-19.1). Among assessed models, elastic net regularization demonstrated best predictive performance in the withheld validation cohort when assessing both long-term opioid use (area under curve [AUC]=0.748) and long-term benzodiazepine use (AUC=0.704). Applying our model to the validation set, patients scored as low-risk demonstrated a 4.8% and 2.4% risk of long-term opioid and benzodiazepine use, respectively, compared to 35.2% and 11.1% of high-risk patients.

CONCLUSIONS

We developed and validated a parsimonious, predictive model to anticipate long-term opioid and benzodiazepine use early after intradural tumor resection, providing physicians opportunities to consider alternative pain management strategies.

A pilot randomized trial of CBT4CBT for women in residential treatment for substance use disorders

INTRODUCTION

Despite the effectiveness of cognitive behavioral therapy (CBT) for treatment of substance use disorder, dissemination to clinical practice is limited due to a range of barriers (e.g., time, cost). Computer-based training for cognitive behavioral therapy (CBT4CBT) offers a feasible and cost-effective opportunity to improve the quality and reach of SUD treatment. Research to date has supported the effectiveness of CBT4CBT in outpatient settings; however, research has not yet tested it in residential treatment.

METHODS

The current study evaluated the feasibility of CBT4CBT as an adjunct to residential treatment in a sample of women with SUDs using a two-arm pilot RCT comparing women randomized to either standard residential treatment plus access to the CBT4CBT program (N = 34) or residential treatment alone (TAU; N = 29). Assessments occurred at baseline, discharge from residential care, and at 4- and 12-weeks post-discharge. The study compared the two groups over the 12-week follow-up period on relapse to any substance (Y/N), relapse to primary substance (Y/N), and days of use using chi-square for categorical and t-tests for continuous measures. The study team also performed a Kaplan-Meier analysis to compare the two groups on time to relapse.

RESULTS

Demographically, the sample was predominantly African American (79.4%), with a mean age of 41.2 years (SD = 12.1). Although the current study was not powered for statistical significance, findings were in the predicted direction, with women in the CBT4CBT group reporting lower likelihood of relapse, longer time to relapse, and fewer days of substance use in the follow-up period compared to women in TAU.

CONCLUSIONS

This study expands the current literature supporting the use of CBT4CBT in outpatient settings. While a fully powered trial should confirm our findings, the current study provides benchmark data on the use of CBT4CBT in residential treatment for women with SUDs.

Relapse prevention group therapy via video-conferencing for substance use disorder: protocol for a multicentre randomised controlled trial in Indonesia

BACKGROUND

Substance use disorder (SUD) is a leading contributor to the global burden of disease. In Indonesia, the availability of formal treatment for SUD falls short of the targeted coverage. A standardised therapeutic option for SUD with potential for widespread implementation is required, yet evidence-based data in the country are scarce. In this study, we developed a cognitive behavioural therapy (CBT)-based group telemedicine model and will investigate effectiveness and implementability in a multicentre randomised controlled trial.

METHODS

A total of 220 participants will be recruited from the social networks of eight sites in Indonesia: three hospitals, two primary healthcare centres and three rehabilitation centres. The intervention arm will participate in a relapse prevention programme called the Indonesia Drug Addiction Relapse Prevention Programme (Indo-DARPP), a newly developed 12-week module based on CBT and motivational interviewing constructed in the Indonesian context. The programme will be delivered by a healthcare provider and a peer counsellor in a group therapy setting via video-conferencing, as a supplement to participants' usual treatments. The control arm will continue treatment as usual. The primary outcome will be the percentage increase in days of abstinence from the primarily used substance in the past 28 days. Secondary outcomes will include addiction severity, quality of life, motivation to change, psychiatric symptoms, cognitive function, coping, and internalised stigma. Assessments will be performed at baseline (week 0), post-treatment (week 13), and 3 and 12 months post-treatment completion (weeks 24 and 60). Retention, participant satisfaction, and cost-effectiveness will be assessed as the implementation outcomes.

ETHICS AND DISSEMINATION

The study protocol was reviewed and approved by the Ethics Committees of Universitas Indonesia and Kyoto University. The results will be disseminated via academic journals and international conferences. Depending on trial outcomes, the treatment programme will be advocated for adoption as a formal healthcare-based approach for SUD.

TRIAL REGISTRATION NUMBER

UMIN000042186.

Adapting behavioural interventions to compensate for cognitive dysfunction in persons with opioid use disorder

Treatment for opioid use disorder (OUD) is often in the context of biobehavioural interventions, consisting of medication for OUD (for example, methadone and buprenorphine), which is accompanied by psychoeducation and/or behavioural therapies. Patients with OUD often display weaknesses in cognitive function that may impact the efficacy of such behavioural interventions. A review of the literature was conducted to: (1) describe common cognitive dysfunction profiles among patients with OUD, (2) outline intervention approaches for patients with OUD, (3) consider the cognitive demands that interventions place on patients with OUD and (4) identify potential accommodation strategies that may be used to optimise treatment outcomes. Cognitive profiles of patients with OUD often include weaknesses in executive function, attention, memory and information processing. Behavioural interventions require the patients' ability to learn, understand and remember information (placing specific cognitive demands on patients). Accommodation strategies are, therefore, needed for patients with challenges in one or more of these areas. Research on accommodation strategies for patients with OUD is very limited. We applied research from populations with similar cognitive profiles to form a comprehensive collection of potential strategies to compensate for cognitive dysfunction among patients with OUD. The cognitive profiles and accommodation strategies included in this review are intended to inform future intervention research aimed at improving outcomes among patients with OUD.

Factors Associated With Relapse in Individuals With Opioid Use Disorder Receiving Suboxone in Rural Areas

BACKGROUND

Opioid use disorder (OUD), including opioid misuse, abuse, and overdose, has evolved into a national crisis with a lasting effect on society, individuals, and health care systems. Although an office-based treatment of Suboxone combined with counseling is a viable option for individuals with OUD and has been shown to reduce utilization of medical services, the relapse rate among those individuals remains high. There is a need to investigate factors associated with relapse to tailor treatment programs in an effort to prevent relapse. This study aimed to examine factors associated with relapse in individuals with OUD receiving Suboxone.

METHODS

A convenience sample was recruited from an outpatient Suboxone facility located in a rural county of New York. Measures included urine drug testing obtained through the medical record, patterns of time to relapse as measured by the Time to Relapse Questionnaire, pain intensity, and a demographic questionnaire. Descriptive statistics, independent t test, and chi-square statistics were utilized for data analysis.

RESULTS

Forty-six patients participated in the study. Length of time in a Suboxone program, scores in sudden and long delay relapse, and the type of treatment program were statistically associated with relapse.

CONCLUSION

This study provided insight regarding factors contributing to relapse and different time-to-relapse styles that could be incorporated into clinical practice to help prevent relapse.

Day-to-day hedonic and calming effects of opioids, opioid craving, and opioid misuse among patients with chronic pain prescribed long-term opioid therapy

ABSTRACT

Concerns have been raised regarding the misuse of opioids among patients with chronic pain. Although a number of factors may contribute to opioid misuse, research has yet to examine if the hedonic and calming effects that can potentially accompany the use of opioids contribute to opioid misuse. The first objective of this study was to examine the degree to which the hedonic and calming effects of opioids contribute to opioid misuse in patients with chronic pain. We also examined whether the hedonic and calming effects of opioids contribute to patients' daily levels of opioid craving, and whether these associations were moderated by patients' daily levels of pain intensity, catastrophizing, negative affect, or positive affect. In this longitudinal diary study, patients (n = 103) prescribed opioid therapy completed daily diaries for 14 consecutive days. Diaries assessed a host of pain, psychological, and opioid-related variables. The hedonic and calming effects of opioids were not significantly associated with any type of opioid misuse behavior. However, greater hedonic and calming effects were associated with heightened reports of opioid craving (both P's < 0.005). Analyses revealed that these associations were moderated by patients' daily levels of pain intensity, catastrophizing, and negative affect (all P's < 0.001). Results from this study provide valuable new insights into our understanding of factors that may contribute to opioid craving among patients with chronic pain who are prescribed long-term opioid therapy. The implications of our findings for the management of patients with chronic pain are discussed.

Mind-body approaches targeting the psychological aspects of opioid use problems in patients with chronic pain: evidence and opportunities

Opioids are commonly prescribed for the management of patients with chronic noncancer pain. Despite the potential analgesic benefits of opioids, long-term opioid therapy (LTOT) may be accompanied by problems such as opioid misuse and opioid use disorder (OUD). In this review, we begin with a description of opioid misuse and OUD and the patient-specific factors associated with these problems among patients with chronic pain. We will focus primarily on highlighting the predominant role played by psychological factors in the occurrence of opioid misuse and OUD in these patients. Several psychological factors have been found to be associated with opioid use problems in patients with chronic pain, and evidence indicates that patients presenting with psychological disturbances are particularly at risk of transitioning to long-term opioid use, engaging in opioid misuse behaviors, and developing OUD. The biological factors that might underlie the association between psychological disturbances and opioid use problems in patients with chronic pain have yet to be fully elucidated, but a growing number of studies suggest that dysfunctions in reward, appetitive, autonomic, and neurocognitive systems might be involved. We end with an overview of specific types of psychological interventions that have been put forward to prevent or reduce the occurrence of opioid misuse and OUD in patients with chronic pain who are prescribed LTOT.

The efficacy of Personalized Normative Feedback interventions across addictions: A systematic review and meta-analysis

Personalized Normative Feedback (PNF) may help address addictive disorders. PNF highlights discrepancies between perceived and actual peer norms, juxtaposed against self-reported behavior. PNF can be self-directed and cost-efficient. Our study estimates the efficacy of PNF alone, and in combination with other self-directed interventions, to address frequency and symptom severity of hazardous alcohol use, problem gambling, illicit drug and tobacco use. We searched electronic databases, grey literature, and reference lists of included articles, for randomized controlled trials published in English (January 2000-August 2019). We assessed study quality using the Cochrane Risk of Bias tool. Thirty-four studies met inclusion criteria (k = 28 alcohol, k = 3 gambling, k = 3 cannabis, k = 0 tobacco). Thirty studies provided suitable data for meta-analyses. PNF alone, and with additional interventions, reduced short-term alcohol frequency and symptom severity. PNF with additional interventions reduced short-term gambling symptom severity. Effect sizes were small. PNF did not alter illicit drug use. Findings highlight the efficacy of PNF to address alcohol frequency and symptom severity. The limited number of studies suggest further research is needed to ascertain the efficacy of PNF for gambling and illicit drug use. Cost-effectiveness analyses are required to determine the scale of PNF needed to justify its use in various settings.

Racial and Ethnic Disparities in Laryngeal Cancer Care

There is a long history of racial and ethnic disparities in healthcare and they continue to persist in contemporary society. These disparities have the potential to negatively affect morbidity and mortality in racial and ethnic minorities diagnosed with laryngeal cancer. Diagnosis, medical treatment, and rehabilitation for laryngeal cancer have improved considerably, leading to improvements in overall survival rates and physical, social, and psychological functioning. Yet members of minority and underrepresented groups are at an increased risk for experiencing reduced access to quality care and delays between diagnosis and treatment, and as a result have lower survival rates. Increasing health providers' awareness of racial and ethnic disparities in laryngeal cancer is necessary to facilitate changes in patient and provider education, clinical practice, and health policies. The purpose of this review is to summarize current literature on disparities in laryngeal cancer diagnosis, treatment, and rehabilitation among Black and Hispanic patients. We present recent data from the Surveillance, Epidemiology, and End Results database to examine trends in laryngeal cancer and patient, provider, and health systems factors that may perpetuate these disparities. In addition, we offer interventions to address racism and other racial and ethnic biases in laryngeal cancer care and describe research and legislative actions that are needed to reduce disparities in this area.

PROTOCOL: Opioid-specific medication-assisted therapy and its impact on criminal justice and overdose outcomes

BACKGROUND

The overlap between criminal justice system involvement and drug use is well-documented, and criminal justice agencies have been particularly overwhelmed by the recent opioid epidemic. Treating opioid (and other substance) addiction as a means to reduce risk for future criminality and improve public safety is inherently a responsibility for the criminal justice system. In turn, the criminal justice system has a responsibility to manage and treat addiction among the individuals under its purview.  Policy recommendations place emphasis on the use of medication-assisted treatments (MAT) as a front-line defense among correctional populations, because its efficacy and effectiveness has been well-established in other contexts.  Despite this, criminal justice agencies have been reluctant or slow to do so.

OBJECTIVES

The current review will provide criminal justice and substance use treatment decision-makers with information regarding the efficacy and effectiveness of opioid-specific MAT on offending and overdose outcomes. Specifically, the authors will address the following research questions: Do opioid-specific MATs reduce the frequency or likelihood of criminal justice outcomes, as defined by official or self-reported indices of criminal reconviction or rearrest, revocation of community supervision, mandated treatment failure, and specialized court docket failure? Do opioid-specific MATs reduce the frequency of opioid overdose among individuals with current or prior self-reported or official record of criminal justice system involvement?

INCLUSION CRITERIA

Studies were required to use strong quasi-experimental or randomized experimental designs. All studies used individual level unit of analysis and examined adults and adolescents who are male, female, or nonbinary and racially/ethnically diverse, with current opioid use and who have current or prior criminal justice involvement. Studies had to prospectively test the effects of heroin and methadone maintenance, buprenorphine, or naltrexone on criminal conviction, arrest, revocation of community supervision, technical probation or parole violation, mandated treatment failure, and specialized court docket failure. Overdose outcomes were also examined for samples in criminal justice settings such as jails, prisons, probation, and parole.

SEARCH STRATEGY AND DATA COLLECTION

This review builds upon a prior review conducted by Egli et al. (2009) and examined studies meeting the inclusion criteria above published between 1960 and October 31, 2020. The following platforms and databases (in parentheticals) were used: EBSCOhost (Criminal Justice Abstracts, SocINDEX with Full Text, Legal Collection, Wilson Omnifile, PsycINFO, Social Work Abstracts, and Women's Studies International [includes grey literature]); ProQuest (Criminal Justice Database, PAIS [includes grey literature], Dissertations and Theses Global [includes grey literature]); Gale (Expanded Academic ASAP, Opposing Viewpoints Resource Center); FirstSearch (GPO Monthly Catalog, PapersFirst [includes grey literature]); ISI Web of Knowledge (Web of Science Core Collection); Office of Justice Programs (National Criminal Justice Reference Service); Summon; and Nexis Uni. The following open access platforms and databases will also be consulted: Elsevier (Scopus [includes grey literature]); Science.gov; ClinicalTrials.gov; WHO International Clinical Trials Registry Platform (ICTRP) portal; and Google Scholar. Search terms were harvested according to their demonstrated success in drawing out relevant and complete results for studies regarding the effectiveness of opioid-specific medication-assisted therapies (MATs). From this process 5 core search strings were created, each one with the same general base terms, but unique outcome measure(s).

ANALYSIS

For binary offending outcomes (e.g., arrest, conviction, incarceration, specialty court failure, mandated treatment failure, or community supervision failure) and overdose outcomes, odds ratios were computed, and for continuous or quasi-continuous outcomes (e.g., total number of arrests), a standardized mean difference type effect size was computed and then transformed into an odds ratio. We used the χ ² test that goes with the forest plot and computed the I ² statistic to assess heterogeneity. Risk of bias was assessed with (1) the revised Cochrane risk-of-bias tool for randomized trials; and (2) the risk of bias in non-randomized studies of interventions assessment tool.

Group versus individual treatment for substance use disorders: a study protocol for the COMDAT trial

BACKGROUND

Alcohol and other drug use disorders contribute substantially to the global burden of illness. The majority of people with substance use disorders do not receive any treatment for their problems, and developing treatments that are attractive and effective to patients should be a priority. However, whether treatment is best delivered in a group format or an individual format has only been studied to a very limited degree. The COMDAT (Combined Drug and Alcohol Treatment) trial evaluates the feasibility, acceptability, and cost effectiveness of MOVE group (MOVE-G) treatment versus MOVE individual (MOVE-I) treatment in four community-based outpatient treatment centres in Denmark.

METHODS

A two-arm non-inferiority trial comparing MOVE-I (Pedersen et al., Drug Alcohol Depend 218:108363, 2020) with MOVE-G a combined group treatment for both alcohol use disorder and drug use disorder. The primary objective is to examine whether MOVE-G is non-inferior to MOVE-I in relation to abstinence from drug and/or alcohol, number of sessions received, and completion of treatment as planned. All participants will receive treatment based on cognitive behavioral therapy and motivational interviewing, vouchers for attendance and text reminders, as well as medication as needed (MOVE). Participants (n = 300) will be recruited over a one-year period at four public treatment centers in four Danish municipalities. A short screening will determine eligibility and randomization status. Hereafter, participants will be randomized to the two treatment arms. A thorough baseline assessment will be conducted approximately 1 week after randomization. Follow-up assessments will be conducted at 9 months post-randomization. In addition, patients' use of drugs and alcohol, and patients' wellbeing will be measured in all sessions. The main outcome measures are drug and alcohol intake at 9 months follow-up, number of sessions attended, and dropout from treatment.

DISCUSSION

The present study will examine the potential and efficacy of combined groups (patients with alcohol and drug disorders in the same group) versus individually based treatment both based on the treatment method MOVE (Pedersen et al., Drug Alcohol Depend 218:108363, 2020).

TRIAL REGISTRATION

ISRCTN88025085 , registration date 30/06/2020.

Opioid Use Disorder: Treatments and Barriers

Over the last decade, opioid use around the world has risen considerably and is projected to continue to rise at an alarming rate. As opioid use rises, so too does the number of people who suffer from opioid use disorder (OUD) and opioid overdose-related deaths. As science and medicine progresses, new medications and therapies have arisen in order to help treat patients suffering from addiction. Treatment can be split into two main domains: pharmacological and non-pharmacological. Buprenorphine and methadone, currently the most prescribed medications for patients suffering from OUD, have been shown to be extremely effective in clinical trials but have significant real-world limitations. Geographical disparities between various locations, physician stigma with prescribing these medications, and training required to prescribe medication can make access to these treatments difficult for patients. Non-pharmacological interventions have also been shown to help with limited efficacy when combined with pharmacological interventions. However, the time and resources required to implement these strategies may be a difficult barrier to overcome. In this review, we assess pharmacological interventions, non-pharmacological treatments, examine barriers to treatment for patients, and propose solutions to bypass these barriers.

The association of prefrontal cortex response during a natural reward cue-reactivity paradigm, anhedonia, and demoralization in persons maintained on methadone

Persons with opioid use disorder (OUD) often experience anhedonia and demoralization, yet there is relatively little research on the pathophysiology of anhedonia and demoralization in OUD treatment and recovery. In the current study, persons maintained on methadone (N = 29) underwent a natural reward-cue paradigm during functional near-infrared spectroscopy (fNIRS) imaging. Natural reward cues included highly palatable food, positive social interactions (e.g., a happy family at the dinner table), and emotional intimacy (e.g. couples embracing or kissing, but no erotic images). Participants also self-reported symptoms of anhedonia on the Snaith-Hamilton Pleasure Scale (SHPS) and demoralization on the Demoralization Scale II (DS-II). Participants who reported clinically-significant anhedonia on the SHPS displayed decreased neural activity in the right prefrontal cortex (PFC) in response to natural reward cues (F(1,25) = 3.612, p = 0.027, ηp2 = 0.302). In linear regression models of positive social cues, decreased neural activity in the right VMPFC was associated with increased SHPS total score (F(1,27) = 7.131, R2 = 0.209, p = .013), and decreased neural activity in an area encompassing the right lateral VMPFC and DLPFC was associated with increased DS-II total score (F(1,27) = 10.641, R2 = 0.283, p = 0.003). This study provides initial evidence that the prefrontal cortex is involved in the pathophysiology of anhedonia and demoralization in persons in recovery from OUD. Anhedonia and demoralization are important treatment outcomes that should be queried along with a constellation of physical and mental health outcomes, to assess areas of needed improvement in methadone maintenance and other OUD treatment modalities.

The effectiveness of an indicated prevention programme for substance use in individuals with mild intellectual disabilities and borderline intellectual functioning: results of a quasi-experimental study

AIMS

To assess the effectiveness of Take it personal!, a prevention programme for individuals with mild intellectual disabilities and borderline intellectual functioning (MID-BIF) and substance use (SU). The prevention programme aims to reduce SU (alcohol, cannabis and illicit drugs) among experimental to problematic substance users.

DESIGN

A quasi-experimental design with two arms and a 3-month follow-up.

SETTING

Adolescents were recruited from 14 treatment centres in the Netherlands specialized in offering intra- and extramural care for people with MID-BIF and behavioural problems.

PARTICIPANTS

Data were collected from 66 individuals with MID-BIF assigned either to the intervention condition (n = 34) or to the control condition (n = 32).

INTERVENTIONS

Take it personal! was designed to target four personality traits: sensation-seeking, impulsive behaviour, anxiety sensitivity and negative thinking. For each of these profiles, interventions were developed that were structurally the same but contained different personality-specific materials, games and exercises. The control group received care as usual.

MEASUREMENTS

Primary outcomes at 3-month follow-up were frequency of SU, severity of SU and binge drinking.

RESULTS

Results showed intervention effects for SU frequency (F(1, 50.43)  = 9.27, P = 0.004) and binge drinking (F(1, 48.02)  = 8.63, P = 0.005), but not for severity of SU (F(1, 42.09)  = 2.20, P = 0.145).

CONCLUSIONS

A prevention programme to reduce substance use among experimental to problematic users with mild intellectual disabilities and borderline intellectual functioning helped participants to decrease substance use frequency and binge drinking.